Intro to Clinics

1. Intro to Clinics Tips and Tricks for Internal Medicine and Family Medicine

2. From Your Upper Classmen Friends It all became worth it when… “...When I had the chance to work with one of the best, most caring physicians that I encountered in medical school, following him from his solitary private practice to the hospital several times each day, where he cared for his patients’ both acute and chronic concerns and addressed their needs completely.” “...When I got the chance to bring in the son of my patient with dementia, and ask him about how he was doing as a caregiver and what we could do for him. He told me no one had ever asked him that before.”

3. What should you buy? • Essentials: • USMLEWORLD!!! • Step Up to Medicine • Kaplan Step 2CK Book • Pocket Medicine • Penlight / Stethoscope light • Pens, snacks (Clifbars, etc) • Case Files • Smart phone: Epocrates, some med calc software

4. What should you buy? • Non-Essentials: • Maxwell Cards • Reflex Hammer • Pretest

5. What goes in all these pockets • Pocket Medicine • Maxwell Cards (if you want) • Reflex hammer (again, somewhat optional) • Papers: H&Ps, signout, articles • PDA • Penlight • Lots of pens • ABG kit, tape, etc (maybe…)

6. General Useful Shorthand

7. Advice: On Imaging

8. Computer Systems • Coast: Check your team, call schedule, etc • Username: ahupuser; password ahupuser • Just type “coast” into the address bar of any Penn Comp • Penn Access Manager --> Link all your signons • Sunrise: All orders; most results --> be the first to know! Flag orders! • Signout: ask your interns/residents if they want you to update. Some do, some don’t. Ask first! • Epic • Medview • Extranet: Log onto Medview from Home • UpToDate from home

9. Sunrise The Sign-Out: Don’t touch unless you’ve asked, but a great way to keep track of the patients overall clinical picture and To-Do list: CHECK OFTEN The MAR: where you can check what pills nursing has given, when the next scheduled dose is These are where you can find vitals and other things like Is/Os A good way to figure out what happened overnight if you don’t hear signout. You can see what orders were placed Where you can see patients’ labs and studies. Cardiology studies (ECHOs), EEGs, and some special radiology may only be available on MedView

10. More Sunrise How to be in the know!

11. Computer Systems: Intranet

12. Structure of Team • Attending • Fellow (on sub-specialty services) • Resident • Two Interns (occasionally 1 intern + 1 sub-I) • You (with perhaps another 200 student) • Nurses • Other staff: Social worker, PT, OT, CNA (Certified Nursing Assistant), Case Manager, Floor clerk, Phlebotomist, etc

13. Typical Day • Pre-Rounds: • Go see your patients, learn about o/n events, check vitals and lab --> get ready to present • Rounds • Work Time • Calling consults • Getting outside records (**ways to make your intern love you**)! • Call • Where you pick up patients and do H&Ps

14. Advice: On Vitals • Bad: Vitals? What vitals? • Good:BP 134/86, HR 72, RR18 • Better:BP121-147/75-92, HR 73-87, RR15-22   • Best: BP 120s-140s/70s-90s, HR 70s-90s.. You get the idea

15. Patient Presentations • Be methodical and thorough with history & exam • In order, same way every time, go back if needed • At least at the beginning, write it out (Type!) • Know everything, but only say what you actually think is important • Think about your assessment as a thesis (ie you think the patient has a pneumonia flare), include any aspects of the H&P, Labs, Imaging that support your thesis • Be prepared to answer other questions • Know the normal values for any labs you state • Follow-Up Presentations: SOAP

16. Topic Presentations • Start with a summary source: UpToDate, NEJM, American Family Physican • Be focused --> brevity is the soul of wit here more than ever • Make a handout, but say more than is on the handout • Incorporate actual evidence (use UpToDate or review) • End strong: Zinger, 3 take-away points

17. Your Greatest Fear … The Shelf! • Find your own studying style • Our basic suggestion: Read StepUp as quickly as possible --> familiarize yourself with the diseases, vocabulary, etc • Questions, Questions, Questions U SMLE!!!! Try to do all the questions, but there are a TON so don’t worry if you don’t do all, but definitely have that as your goal • Know: Common presenting symptoms, Best diagnostic tests, Treatment • Use Family Medicine time wisely

18. Attire • My basic approach: Never give anyone a reason to dislike you or judge you • Assume nothing: Wear nice clothes + white coat as baseline • For call days, ask your resident about scrubs • Cell Phone etiquette: People will assume you’re texting or goofing off. • Always on vibrate • Never use on rounds --> announce exceptions loudly

19. Feedback • Ask for it from Attendings / Residents • Attendings like to be asked proactively for feedback, midway through your time with them • Residents are more likely to offer real, constructive feedback to help you improve • ASK SPECIFICS: ie, I’m really working on making my presentations concise and to the point, do you have any feedback for me on that or suggestions for how I could continue to improve? That way you can do something very concrete and they can say in their evals that you used feedback to improve!

20. Family Medicine • You will be placed at an outpatient practice… some will have residents, but in most you will work directly with the attending • Be ready to get thrown into seeing patients • Your H&Ps will be less thorough than in the hospital. • Be “problem” oriented and try to help the patient identify the biggest “problem”… Some will come in with many issues that you may not be able to address in one visit

21. Family Medicine: What to Review • Look over the last chapter in Step Up to Medicine before beginning the rotation • Know Framingham Risk calculation • Review musculoskeletal exams – knee, shoulder (will need this for the exam too) • Some practices will see more ob-gyn than others… if you feel like you are seeing a fair amount of OB, may be helpful to review the prenatal/postnatal care section of an OB-GYN book

22. Family Medicine Exam • One component is preforming a joint (shoulder or knee) exam on a standardized patient • The other component is a multiple choice test based on the computer modules you are required to do • The test is somewhat detail-oriented and less big-picture. Do not skip over the sections about cultural competency in the online cases… they can be tested (know the latino principals of respecto… etc) • Review all the guidelines presented in the online modules – like when to do pap smears, stress test, etc

23. Staying Sane • Biggest challenges • Schedule • Interpersonal work load • Not seeing your friends • Tim’s Solution: • Institutionalize time with those you care most about • Don’t let your empathy get fatigued! Taking an extra moment to listen to your patient is a good way to improve patient care, help your team, and make the experience more fulfilling for you!

24. Random • Go to Intern Report --> good learning and good eating • When your resident tells you to leave, leave! ␣ • Always be on time • Have fun

25. Advice: On Clinic Grades • The Three A’s: • Affability (enthusiasm for everything!) • Availability • Ability

26. Support Systems Suite 100: - JoMo, Barb, Helene - Tutors set up through suite 100 Organized counseling: - CAPS: http://www.vpul.upenn.edu/caps/ - Therapists in the community (Barb from Student Affairs can provide names and contact info) - Paired mentoring: SNMA, LMSA, Elizabeth Blackwell, House mentors Other people to turn to: - Doctoring preceptors - Advisory deans - Clerkship directors (it’s really ok to talk to them!) - Mentors you have connected with in pre-clinical years (through clinics, volunteering, etc) - Friends and family outside of medicine

27. Supplemental Stuff • UpToDate from Home • Access the hospital's Extranet at https://extranet.uphs.upenn.edu/ • Use your MedView username / password to log in • Create a bookmark on your home page for UpToDate • Click on the "+" that's on the far right side of the "Web Bookmarks" heading • Name your bookmark and put this URL in the URL spot: http://uphsxnet.uphs.upenn.edu/uptodate • Click on new bookmark that's now on your home page • Use UpToDate like you would from on campus • HUP OR Schedule: • Homepage: Left hand side, click on Departments-->Perioperative Services-->OR Schedule. The user name and password are both hupor

28. Supplemental Stuff • Bug Drug: UPHS guidelines for anti-microbial therapy • Pulse: • Phonebooks for each hospital • #s for Consult services • Lots of assorted resources, guidelines, forms • Phone #s to store in your cell • Hospital operator • General lab